feedm.e. malnutrition awareness and education for hospital ......6671 ± 2351 4949 ± 2466 0.018*...
TRANSCRIPT
feedM.E. Malnutrition
Awareness and Education
for Hospital Administrators
5001 1113 0139 A 1
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Malnutrition Is a Problem That Can Be Solved
Worldwide 20 to 50% of
hospitalized patients are
malnourished—a situation with
serious negative impact on
patient outcomes and
healthcare costs.
THE PROBLEM
Nutrition intervention, such as
oral nutrition supplements
(ONS) immediately upon
admission, helps lessen
adverse effects of
malnutrition and enhance
patient response to treatment
and recovery.
The feedM.E.
Nutrition Care
Pathway helps make
nutrition intervention
stepwise and simple.
THE SOLUTION
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Nutrition Practices for Hospital Administrators
o Malnutrition takes high
health and financial tolls.
o Nutrition interventions
improve patient outcomes
and cut hospital costs.
o Common barriers impede
best-practice nutrition but
can be overcome with
guidelines, protocols,
training and reinforcement.
o To identify risk of
malnutrition and to guide
nutrition care, follow our
Nutrition Care Pathway.
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Malnutrition prevalence • Health tolls • Excess healthcare costs
Evidence shows that malnutrition worsens clinical outcomes
and adds to the overall costs of care.
Malnutrition Is Common and Costly
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50% of
European hospital
patients > 80 years
and nursing home
patients were at risk
of malnutrition3
27% in Beijing
hospitals at
malnutrition
risk9
42.5% in Jinling
hospital were
malnourished based
on low body mass
index or recent
weight loss10
32%
malnutrition
prevalence in
56 hospitals in
Australia and
New Zealand8
Malnutrition Is Common in Hospitals Worldwide
1. Norman K, et al. Clin Nutr. 2008;27:5-15. 2. Vanderwee K, et al. Clin Nutr. 2010;29:469-476. 3. Kaiser MJ, et al. J Am Geriatr Soc. 2010;58:1734-1738. 4. Meijers JM, et al. Br J Nutr. 2009;101:417-423. 5. Barreto
Penie J. Nutrition. 2005;21:487-497. 6. Waitzberg DL, et al. Nutrition. 2001;17:573-580. 7. Charlton KE, et al. Nutr Health Aging. 2010;14:622-628. 8. Agarwal E, et al. Clin Nutr. 2012;31:41-47. 9. Liang X, et al. Asia Pac
J Clin Nutr. 2009;18:54-62. 10. Zhang L, et al. Asia Pac J Clin Nutr. 2013;22:206-213.
43% in Cuban
hospitals were
moderately
malnourished and
11% were severely
malnourished5
48% in
Brazilian
hospitals were
malnourished6
Prevalence of hospital malnutrition ranged between 20 and 50%1
Malnutrition risk in
43% of hospitalized
elderly Belgian
patients; 33%
malnourished2
19% of Dutch
nursing home
patients were
malnourished4 51% of older
Australians in
rehabilitation
hospitals were
at risk of
malnutrition7
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Malnutrition Is Associated With Illness, Injury, and Hospitalization
1. Imoberdorf R, et al. Clin Nutr. 2010;29:38-41
2. Krumholz HM. N Engl J Med. 2013;368:100-102.
3. Li HJ, et al. J Adv Nurs. 2013;69:1691-1703.
4. Hiesmayr M, et al. Clin Nutr. 2009;28:484-491.
Risk of dying increases when food
intake is limited by illness or injury4
Loss of lean body mass delays
recovery and impedes rehabilitation3
Hospitalization itself often
worsens nutritional status2
Anyone who is sick or injured is at risk of
malnutrition, especially older people1
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Imoberdorf R, et al. Clin Nutr. 2010;29:38-41.
More than 1 in 5 patients over age 65 was severely undernourished or at
risk for under-nutrition upon hospital admission
Risk for Malnutrition Increases With Age
Switzerland
Diminished functional status (handgrip strength)
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Malnutrition Has Adverse Impacts on Outcomes
1. Loser C. Dtsch Arztebl Int. 2010;107:911-917. 2. Shepherd A. Nurs Times. 2009;105:18-20.
DECREASES1,2
GI, pulmonary,
and renal function
Recovery from
illness
Mental state
Immunocompetence
Recovery from injury
Quality of life
INCREASES1,2
GI, pulmonary,
and renal function
Overall
complication rate
Rate, duration,
severity of infections
Hard-to-heal wounds,
pressure ulcers
Immobility,
risk of falling
Need of help
and care
Mortality risk
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Malnutrition Increases Risk of Post-surgical Complications
Fry DE, et al. Arch Surg. 2010;145:148-151.
9
Pre-existing malnutrition increases risk for post-surgical
complications by 2- to 5-times.
USA
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1. Schneider SM, et al. Br J Nutr. 2004;92:105-111. 2. Lee S, et al. Yonsei Med J. 2003;44:203-209.
Malnutrition Increases Risk of Hospital-acquired Infections
10
France1
Malnutrition increases risk of
hospital-acquired infection
nearly 5-fold (OR, 4.98).
Korea2
Severely malnourished
ICU patients were 2.1
times more likely to get
an infection.
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Malnutrition Is Associated With Falling in Hospitals
1. Bauer JD, et al. J Hum Nutr Diet. 2007;20:558-564.
Well-nourished
by SGA* n=27; mean ± S.D.
Malnourished
by SGA* n=22; mean ± S.D.
P-value
Age (years) 69.8 ± 14.1 72.8 ± 14.1 0.453
MST,* admission
No risk (0,1)
Risk (≥ 2)
21
6
6
16
< 0.001*
Weight (kg) 75.4 ± 13.9 63.0 ± 12.8 0.002*
Body mass index 25.9 ± 3.9 22.1 ± 3.4 0.003*
Energy intake
(Kj)
6671 ± 2351 4949 ± 2466 0.018*
Protein intake (g) 77.2 ± 29.5 56.4 ± 30.4 0.022*
*Malnutrition screening Tool, MST. Subjective Global Assessment, SGA. Nutritional status was determined as well-nourished (SGA A)
or Malnourished (SGA B + C); statistical significance is reported at P< 0.05.
Australia: patients who fell during hospitalization
‘Fallers’ had a high prevalence of malnutrition; nutrition intervention is
recommended for people who fall during hospitalization.
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Malnutrition Negatively Impacts Health-related QOL
12
EuroQol-5D QOL Dimensions
Kvamme JM, et al. Qual Life Res. 2011;20:575-582.
Quality of Life
Pain/ discomfort
Mobility
Self-care Usual
activities
Anxiety/ depression
Norway
n= 3286 people
aged 65-87 yrs
Health-related Quality of Life
(HRQoL) was significantly
reduced in older people with
increased risk of
malnutrition.
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Malnutrition Is Associated With Serious Morbidity and Mortality
13
1. Sullivan DH, et al. J Gen Intern Med. 2002;17:923-932. 2. Stratton RJ, et al. Br J Nutr. 2006;95:325-330.
3. Correia MI, Waitzberg DL. Clin Nutr. 2003;22:235-239. 4. Prasad N, et al. J Ren Nutr. 2010;20:384-391.
Brazil3: In-hospital
mortality was higher in
malnourished than in
nourished patients
(12.4% vs 4.7%).
India4: Malnourished
dialysis patients were at
3-fold higher risk of
mortality compared to
nourished peers.
UK2: Hospital patients at
high risk for malnutrition had
greater post-release
mortality compared to low-
risk patients (24% vs. 5% at
3 months).
USA1: Older hospital patients
with low BMI (< 22 kg/m2)
were more likely to
experience life-threatening
complications than were
those with higher BMI
(15.4% vs. 4%).
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Financial Costs Associated With Malnutrition Are High
1. Freijer K, et al. Clin Nutr. 2013;32:136-141. 2. Lim SL, H, et al. Clin Nutr. 2012;31:345-350.
Netherlands1
Added costs of care for
managing disease-related
malnutrition was estimated as
2.1% of the country’s total
national health expenditures.
Across Europe, such costs
would total €120 billion
annually.
Malnourished patients
had longer stays in hospital
(6.9 days vs 4.6 days,
P < 0.001) and 2-fold higher
rates of readmission within
15 days compared to
adequately-nourished
peers—both with expensive
consequences.
Singapore2
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Malnutrition and Increased Daily Hospital Costs
Correia MI, Waitzberg DL. Clin Nutr. 2003;22:235-239.
Brazil
N=709 patients in 25 hospitals
15
Malnourished patients had higher daily costs of care, and they stayed longer in the
hospital (16.7 days vs 10.1 days for nourished patients) causing still greater costs.
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Malnutrition and Increased Total Hospitalization Costs
Amaral TF, et al. Clin Nutr. 2007;26:778-784.
Portugal n=469 patients
16
The hospitalization cost for a malnourished patient was more than double
that of a patient who was not classified as nutritionally-at-risk.
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Oral nutrition supplements • Outcome benefits • Cost savings
Clinical evidence underscores advantages of nutrition intervention.
Feeding Hospitalized Patients: the Impact
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Outcome Benefits With ONS
Outcome benefit Study design and findings
Lower incidence of pressure ulcers
Meta-analysis of results from 4 RCTs showed significantly lowered
incidence among elderly hospitalized patients (OR 0.75) who used
ONS (2-26 weeks) compared to non-users.1 Studies were done in
Switzerland, Sweden, France, and the Netherlands.
Greater handgrip strength
Meta-analysis of results from 4 RCTs showed that ONS users
(mean age > 65 years) had significantly improved handgrip strength
compared to controls.2
Studies were done in the UK, Sweden, and Germany.
Improved QOL
During a 3-month post-hospitalization interval, malnourished
patients who received individualized nutrition care with ONS and
dietary counseling scored higher on all 8 QOL scales, compared to
only 3 scales with dietary counseling.3 This study was conducted in
Germany.
Reduced mortality risk
Meta-analysis of nutrition trials in older people.4 In subgroup
analysis of those who were undernourished, ONS use significantly
reduced risk of mortality by more than 20%. Studies were done at
sites around the world.
Randomized, controlled trial, RCT; odds ratio, OR; oral nutrition supplements, ONS; quality of life, QOL 1. Stratton RJ, et al. Ageing Res Rev. 2005;4:422-450. 2. Cawood AL, Elia M, Stratton RJ. Ageing Res Rev. 2012;11:278-296.
3. Norman K, et alEur J Clin Nutr. 2011;65:735-742. 4. Milne AC, et al Cochrane Database Syst Rev. 2009:CD003288.
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Oral Nutrition Supplement Use Lowers Costs of Hospital Care
19
Philipson TJ, et al. Am J Manag Care. 2013;19:121-128.
USA Database of 44 million inpatient episodes, with >700,000 episodes that included the use of ONS; each
ONS-user was paired with a non-user who had a similar health condition (propensity matching)
ONS use was associated
with 21.6% reduction in
hospitalization cost
Each dollar spent on ONS
generated $52.63 in savings
from reduced episode
cost
EPISODE COST
ONS use was associated with
21.0% reduction in LOS
LENGTH OF STAY ONS was associated with a 6.7%
reduction in probability of 30-day
readmission
Each dollar spent on ONS
generated at least $2.56
from avoided 30-day
readmissions
30-DAY
READMISSION
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Health Benefit: Fewer Complications in Hospitals
20
Baltimore and Beijing
n=1831
Jie B, et al. Nutrition. 2010;26:1088-1093.
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Norman K, et al. Clin Nutr. 2008;27:5-15.
MALNUTRITION
MORBIDITY MORTALITY
READMISSIONS TREATMENT LENGTH OF STAY
INCREASED COST
Health Tolls and Financial Costs: Summary
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Barriers • Nutrition culture • Nutrition guidelines • Training and education
Achieving optimal nutrition starts at the top.
Common Barriers and Strategies to Achieve Best-practice Nutrition
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Too Often Patients’ Nutritional Needs Are Overlooked and Under-treated
o Only 50% of units conducted routine
nutrition screening on admission
o Even when energy goal was specified,
43% of patients did not meet goal
Schindler K, et al. Clin Nutr. 2010;29:552-559.
Europe-wide survey
of nutrition practices
in hospitals
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Too Often Patients’ Nutritional Needs Are Overlooked and Under-treated
o 55% of malnourished patients ate less
than half of the food offered
Agarwal E, et al. Clin Nutr. 2012;31:41-47.
24h audit of nutrition
care in Australian
hospitals
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Too Often Patients’ Nutritional Needs Are Overlooked and Under-treated
o In Chinese teaching hospitals, the proportion
of malnourished patients went from 8.2% on
admission to 11.5% at discharge.1
o Stroke patients hospitalized in South Korea
deteriorated from 12.2% undernourished at
baseline to 19.8% one week later.2
1. Liang X, et al. Asia Pac J Clin Nutr. 2009;18:54-62. 2. Yoo SH, et al. Arch Neurol. 2008;65:39-43.
Nutritional status worsens
during hospital stay
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Barriers to Best-practice: Time, Training, Money
Perceived barriers to updating
nutrition practice1,2 Why overcome this barrier?
Practice change takes time
Adoption of standardized, practical protocols
makes feeding decisions stepwise and logical,
which saves time.
Practice change requires staff
education and training
Achieving better nutritional status for patients
improves clinical outcomes and lowers costs of
care.
Practice change will cost a lot
Due to the high costs of care for malnourished
patients, hospitals can’t afford not to improve
nutrition care.
1. Cahill NE, et al. J Crit Care. 2012;27:727-734. 2. Jones NE, et al. Nutr Clin Pract. 2007;22:449-457.
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5 Steps to Overcome Barriers and Achieve Best-practice Nutrition
Know
nutrition
guidelines
OVERCOME
BARRIERS
Monitor
Progress
Create a
nutrition
culture
Educate and
train staff
Empower
champions
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Create a Culture That Values Nutrition
Mission and goals: NUTRITION
Guidelines
Education
Policies & Protocols
Training
Reinforce messages, refresh training
Guidelines
Training
Brantley SL. Nutr Clin Pract. 2009;24:335-343.
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Education and Training
• Grand rounds
presentations
• In-service training
sessions
• Workshops
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Education and Training
• Computer-based
learning modules
• Bedside instruction
for small groups or
one-on-one training
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Education and Training
• Visual reminders
such as posters
and checklists
• feedM.E. and other
Abbott Nutrition
training materials
as resources
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Education and Training
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Know ICU nutrition
Nutrition support comfort
Importance of nutrition
1. Behara AS, et al. JPEN J Parenter Enteral Nutr. 2008;32:113-119. N
Evidence that healthcare professionals
need and want nutrition education and training USA: Attending physicians, fellows, and residents waited an average of 2.4,
1.8, and 2.6 days before addressing nutritional status in critically ill patients.
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Nutrition Support Teams and “Champions” Help Overcome Barriers
33
1. Delegge M, et al. Nutr Clin Pract. 2010;25:76-
84. 2. Mo YH, et al. Yakugaku Zasshi.
2011;131:1827-1833. 3. McClave SA, et al.
JPEN J Parenter Enteral Nutr. 2010;34:123S-
132S. 4. Thoresen L, et al. J Hum Nutr Diet.
2008;21:239-247. 5. Bourgault AM, et al. Crit
Care Nurse. 2007;27:17-22, 25-19.
OVERCOME
BARRIERS
Nutrition
Support
Teams1,2
Nutrition
Specialist
Physicians3
Dietitians4 Nutrition
“Champions”5
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Screen • Intervene • Supervene
Basic nutrition care is logical and stepwise.
Take Action: Follow the Nutrition Care Pathway
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Make Nutrition Screening a Routine Part of Care
Consider immediate
dietary fortification
or oral nutrition supplement
for all at-risk patients
Use alternate
protocol for end-of-
life patients
Screen for malnutrition risk on admission
• Does the patient have illness/injury that
has malnutrition risk?
• Appetite loss?
• Weight loss?
Screen and intervene on admission
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Intervene and Supervene
Assess needs and intervene with nutrition during hospitalization.1
Use Subjective Global Assessment (SGA)2
and other tools for malnutrition diagnosis
Route, access,
and timing
Select a
formula
Set energy and
protein goals
How and when? What? How much?
Track and modify nutrition in hospital
Plan for post-discharge nutrition
Plan for hospital nutrition
1. Correia M et al. J Am Med Dir Assoc. 2014;15:544-550
2. Detsky AS, et al. JPEN J Parenter Enteral Nutr. 1987;11:8-13.
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Choose Nutrition Intervention
Modify oral diet and/or use oral nutrition supplements
Use tube-fed enteral nutrition therapy
Use parenteral nutrition therapy
Hamilton C, Boyce VJ. JPEN J Parenter Enteral Nutr. 2013;37:808-815.
Ro
uti
ne r
esc
reen
ing
an
d
reas
sessm
en
t
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Correia ITD, et al. 2013. Curr Opin Clin Nutr: Submitted.
Consider immediate
dietary fortification
or oral nutrition supplement
for all at-risk patients
Use alternate protocol
for end-of-life patients
Screen for malnutrition risk on admission
• Does the patient have illness/injury that
has malnutrition risk?
• Appetite loss?
• Weight loss?
Use Subjective Global Assessment (SGA)2
and other tools for malnutrition diagnosis
Route, access,
and timing
Select a
formula
Set energy and
protein goals
How and when? What? How much? Track and
modify
nutrition in
hospital
Plan for post-
discharge
nutrition
Plan for hospital nutrition
Ro
uti
ne r
esc
reen
ing
an
d r
eas
sessm
en
t
Intervene With Nutrition in Hospital; Supervene With Post-discharge Nutrition Care
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Call to Action
NUTRITION CARE AT YOUR HOSPITAL
Know what to
do, and train
staff to do it
• Know evidence-based
nutrition guidelines.
• Use nutrition protocols.
• Train staff on best-nutrition
practices.
• Use teams/champions to
sustain quality care.
• Update practices and
training regularly.
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Call to Action
NUTRITION CARE AT YOUR HOSPITAL
Evaluate
practice; adjust
and reassess
care processes.
• Benchmark practices and outcomes.
• Discuss findings with colleagues.
• Set change goals, e.g., reduce
practice variation, contain costs,
increase compliance.
• Implement changes, as needed, with
refreshed policies and training.
• Monitor compliance and outcomes;
share results with colleagues.
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Take-home Messages on Hospital Nutrition Care
Malnutrition has negative effects on outcomes and cost of care.
Time, money, and training are common barriers to adoption of best-practice nutrition—but such barriers can be overcome.
A Nutrition Care Pathway guides nutrition care for hospitalized patients who are malnourished or at risk.
Nutrition interventions decrease morbidity, shorten LOS, lower mortality, reduce readmissions, and lower overall costs of care.
for Hospital
Administrators
5001 1113 0139 A 1